🩺 Record Detail

Patient Info

Name: Simlen Parveen
Age: 29 years
Date: 2025-05-30 13:21:14

Transcript

[00:00 → 00:05] We are coming, Doctor.
[00:05 → 00:06] Yes, come in.
[00:06 → 00:08] Take your seat.
[00:08 → 00:10] Thank you, Doctor.
[00:10 → 00:12] What's your name?
[00:12 → 00:15] Simlen Parveen.
[00:15 → 00:17] And how old are you?
[00:17 → 00:20] I'm 29.
[00:20 → 00:21] Okay.
[00:21 → 00:22] Now, tell me.
[00:22 → 00:25] What are the problems that you're facing?
[00:25 → 00:27] Since you're still in night,
[00:27 → 00:29] I've been having serious stomachache.
[00:29 → 00:31] I took an antested last night,
[00:31 → 00:34] but the pain was still the same.
[00:34 → 00:37] Hmm. Any other symptoms?
[00:37 → 00:40] Yeah, I also had about some vomit in last night.
[00:40 → 00:43] And studio morning as well.
[00:43 → 00:46] Do you have a headache?
[00:46 → 00:48] No.
[00:48 → 00:52] Did you have this kind of stomachache before?
[00:52 → 00:54] Yes, Doctor.
[00:54 → 00:56] I had it worse before.
[00:56 → 00:58] How many days ago?
[00:58 → 01:00] Almost three months ago.
[01:00 → 01:05] But at that time, the pain stopped after I took an antested.
[01:05 → 01:07] Please lie on that bed.
[01:07 → 01:09] I have to check.
[01:09 → 01:12] Okay, Doctor.
[01:22 → 01:24] Does it hurt here?
[01:24 → 01:25] Yes, Doctor.
[01:25 → 01:26] It hurts a lot.
[01:26 → 01:29] Okay, you can get it now.
[01:29 → 01:33] Is it something serious, Doctor?
[01:33 → 01:35] I can't say now.
[01:35 → 01:37] I'm writing down some tests.
[01:37 → 01:39] Try to do this by today.
[01:39 → 01:41] But what about now?
[01:41 → 01:44] I can't even work properly because of the pain.
[01:44 → 01:45] I understand.
[01:45 → 01:49] I'm giving you an injection for temporary relief.
[01:49 → 01:51] Injection?
[01:51 → 01:55] Don't you have any medicine?
[01:56 → 01:57] Why?
[01:57 → 01:59] Are you scared of injections?
[01:59 → 02:01] It's not like that.
[02:01 → 02:06] I mean, it would be better if you could give me some medicine.
[02:06 → 02:07] Nothing will happen.
[02:07 → 02:09] You won't even feel it.
[02:09 → 02:11] Look at that side.
[02:11 → 02:13] Please, Doctor.
[02:13 → 02:15] Be careful.
[02:15 → 02:18] You can open your eyes now.
[02:18 → 02:21] It's already done.
[02:21 → 02:23] It's done.
[02:23 → 02:24] Thank you so much.
[02:24 → 02:27] I did not feel anything at all.
[02:27 → 02:32] After receiving the test reports, bring them to me as soon as possible.
[02:32 → 02:35] So, there's nothing to fear, right?
[02:35 → 02:37] Don't be so scared beforehand.
[02:37 → 02:39] Let's see the reports first.
[02:39 → 02:42] You want to give me any medicines, Doctor?
[02:42 → 02:43] Hmm.
[02:43 → 02:45] I'm prescribing this medicine.
[02:45 → 02:47] It's just for today.
[02:47 → 02:49] Take it after your dinner.
[02:49 → 02:51] Okay, Doctor.
[02:51 → 02:53] Where shall I submit the fees?
[02:53 → 02:56] Please submit that in the cash counter.
[02:56 → 02:58] Thank you, Doctor.
[02:58 → 02:59] Welcome.

Clinical Notes

Subjective

  • Patient: Simlen Parveen, 29 years old.

  • Primary Concern:

  • Presenting with severe stomachache since last night, despite taking an antacid.

  • Experienced vomiting last night and this morning.

  • Previous history of similar stomachache three months ago, relieved with antacid.

Objective

  • No relevant data.

Assessment

  1. Gastric Pain: Acute onset of severe stomachache with associated vomiting, warranting further investigation.

Plan

  1. Diagnostics:

  2. Order tests to investigate the cause of stomach pain.

  3. Treatment:

  4. Administered an injection for temporary relief.

  5. Prescribed medication to be taken after dinner for the day.

  6. Follow-Up:

  7. Instructed the patient to bring test reports promptly for review.

  8. Financials:

  9. Directed the patient to submit fees at the cash counter.

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